Why couple infertility is historically a female‐driven problem?

Abstract

Background

The history of studies in the field of infertility represents a chapter of great interest in gender issues.

Objectives

This paper aims to delve deep into the historical roots of the aspect of gender inequality related to couple infertility, with a journey back in time, from classical antiquity to the contemporary age, reporting junctions and metaphors linked to particular historical moments as well as to cultural and religious constructs.

Methods

This is a narrative review based on an extensive literature search of publications regarding the role of women in couple infertility over the centuries.

Results

Rarely in the ancient world, male infertility was taken into consideration, and the sources deal with it mainly indirectly. This attitude of “blaming” the woman for the lack of children had, in fact, strong social implications, which only the scientific research of recent years has managed to bring back into the context of a more egalitarian approach.

Conclusions

In the “journey” narrated in this article, the reader starts from the responsibility of couple infertility attributed exclusively to women in some ancient societies, whose central role was determined by their ability to procreate, going up to the medicalization of infertility in the contemporary age, which contributed to sharing with men this participation in the impossibility of having children.

1. INTRODUCTION

Despite the World Health Organization's (WHO) emphasis on gender equity as a cornerstone of human right approaches to healthcare at all levels, health barriers toward considering that both sexes equally contribute to infertility are difficult to break down. ¹ This is not only a function of national health programs with gender differentials in access to and uptake of health services dedicated to reproductive medicine but also of social and cultural attitudes. In fact, despite the increasing evidence of a male factor as the unique or co‐existing cause of couple infertility in almost 50% of the cases, public opinion on infertility as a first‐driven female problem has remained sharply unchanged over time. ² Consequently, men have often been marginalized during the process of care, thus generating an extreme delay in entering the appropriate diagnostic and therapeutic workup. Noteworthy, this is not only a gender‐inequality issue but also a major threat concerning denatality: very often, the male partner is referred to the andrologist only when no female causes for infertility emerge from the long, complex (and sometimes invasive) workup on the woman. Therefore, several preventable and reversible male conditions underpinning couple infertility are often underdiagnosed and undertreated.

Historians admit that it is difficult to reconstruct the history of infertility ³ , ⁴ as it is perceived as an “experiential state that exists as an absence (the failure to engender pregnancy), that plays out on the bodies of women (a historically marginalized group), and that […] often further stigmatizes its subjects (thus rendering them inarticulate or silent)”. ⁵

Infertility, which prevents reproduction, has always been a social problem, particularly in the past, when death rates were high and society itself periodically suffered from demographic decreases. This problem jeopardized the permanence of a family and constituted a threat to the existence of a community. In the past, virility was an important requirement for certain forms of patriarchy. Fertility and virility were the prerequisites for achieving an adequate social status; bearing children was important to men's social position and the fulfilment of their patriarchal roles.

The sterile or impotent man could not become a father, nor be able to sexually satisfy his wife, and could be betrayed. To ease this tension, it was easier to attribute reproductive failure to the woman. On the other hand, because women's role within the family and community depended in great part on their role as mothers, infertility was an upsetting medical and social condition.

The social dimension of infertility has further burdened the search for its causes and determinants among the two partners. Responsibility aspects for infertility include which partner in an infertile couple is believed to be the source of infertility and the role played by both the patient and the physician in the diagnosis and treatment of infertility.

While modern science shows that male and female factors equally contribute to couple infertility, it is generally believed that most ancient civilizations attributed infertility to women. Instead, there are numerous cases of infertility in male patients given in classical texts; however, male infertility is obfuscated or ignored either in ancient medical books or by modern scholars. As conception and gestation occur in the female body, it was natural that ancient medical writers focused on women, but the ancients fully understood that some men are unable to reproduce and consequently developed measures that they believed could help them. Nevertheless, there was a profound difference: while a woman's childlessness was considered dangerous to her general health and required medical attention, male infertility was not thought to be related to health status and was not particularly problematic in the medical tradition. ⁶

Recent ethnographic research highlights that healthcare professionals are inclined to use less direct or even representative language to discuss infertility issues with their male patients. ⁷ A double and evasive speech hinders men from identifying themselves as having a fertility problem. This contrasts with the healthcare professional's practice for female infertility and women's greater bodily involvement in the treatment of it. ⁸

In this context, this paper aims to delve deep into the historical roots of the current gender inequity in the field of infertility.

1.1. Classical antiquity

Doctors and philosophers of classical antiquity have addressed the issue of male infertility, trying to explain and attributing it to something outside of human control that depends merely on the constitution of the body or on lifestyle factors that could lead to the loss of reproductive ability in men. In both cases, it was generally untreatable. ⁹

Hippocratic writers and Aristotle are the main sources, but, as non‐procreation had no direct effect on the general well‐being of a man, the identification of particular cases of male infertility must be searched not in medical writings but rather in ritual practice and legal disputes. There is also archaeological evidence of men's fertility demands in the form of votive offerings and inscriptions, which appear in the sanctuaries of the Greek world, even though anatomical votives in the shape of men's genitalia do not allow to establish a clear link to male (in)fertility since they may be indicative of totally different organic problems. ⁶

In the Corpus Hippocraticum, which collects all the works attributed to Hippocrates, the reproductive processes and potential difficulties of conceiving are extensively covered, but only two works directly relate to men in the context of reproductive failure. The first one is a discussion of the traditional lifestyle of the Scythians, an ancient tribe that occupied vast areas east of the Black Sea in the treatise of Airs, Waters and Places (20‒21), and the second one is a voice in the Aphorisms (5.62‒3), respectively ¹⁰ : “They [Scythians] grow up flabby and stout for two reasons. First because they are not wrapped in swaddling clothes […] nor are they accustomed to horse riding as children which makes good figure. Secondly they sit about too much […]. People of such constitution cannot be prolific. The men lack sexual desire because of the moistness of their constitution and the softness and coldness of their bellies, a condition which least inclines men to intercourse […]. They are weak in the sexual act when they do have intercourse. These reasons suffice as far as the men are concerned […]”; “Women, who have the uterus cold and dense do not conceive; and those who have the uterus humid do not conceive, for the semen is extinguished, and in women whose uterus is very dry, and very hot, the semen is lost from the want of food; but women whose uterus is an intermediate state between these temperaments are fertile. Similarly, with males. Either because of the rarity of the body the breath is borne outward so as not to force along the seed; or because of the density of the body the liquid does not pass out; or through the coldness it is not heated so as to collect at this place; or through the heat this same thing happens. ¹⁰ ”

It is interesting to note that, in some inscriptions, the man questions the divinity to foresee if he can have children with a particular woman. This has led to the idea that the combination of particular partners could be held responsible for the lack of children as if infertility could be attributed to the incompatibility of the couple. ¹¹

1.2. Roman world

In the Roman world, both in the Christian age and previously (see the mythical birth of Asclepius and the Etruscan tradition), fertility was considered a central point in the life of the couple, so much so that cesarean section deliveries were accepted on a dead woman, first to raise the demographic increase and then to protect the sacredness of life. ¹²

It is no coincidence that Galen, in the 2^nd century AD, developed the so‐called hydrostatic docimasia to understand whether a fetus was born alive or dead. ¹³

The historian Appian of Alexandria—who lived between the 1^st and 2^nd century AD—in his “Historia Romana” (2, 14, 99) narrated that Marcus Porcius Cato Uticensis “had married Marcia, the daughter of Philippus, as a girl; was extremely fond of her, and she had borne him children. Nevertheless, he gave her to Hortensius, one of his friends— who desired to have children but was married to a childless wife— until she bore a child to him also, when Cato took her back to his own house as though he had merely lent her. ¹⁴ ” The topic was the subject of numerous rhetorical controversies in the legal field, but it is worth emphasizing how the responsibility for Hortensius’ lack of children was attributed to his wife. In reality, the union with Lutatia, Hortensius’ first wife, had produced him a child; this son is known to have inherited his father's property, therefore, the union with Marcia produced no children. The responsibility for infertility would therefore not be attributed to the wife Lutatia, given that Marcia's fertility was widely proven. ¹⁵ As a matter of fact, some legal situations cited by the orators provide interesting approaches to understanding male infertility in disputes over the inheritance of assets. ¹⁶

1.3. Middle ages

Infertility was a considerable problem also in medieval Europe, which presented a high infant mortality rate: when women could not bear a child, their husbands could invalidate the marriage; but the responses were different in the different socio‐cultural contexts. Within this framework, the history of Catherine de’ Medici is worthy of mention. In 1531, Catherine was negotiated to marry Henry Duke of Orleans, the second son of Francis I, the King of France, with a dowry that included a huge amount of money and land. After 10 years of marriage without progeny, King Francis made a public declaration and confirmed that his son consummated the marriage with Catherine. However, Catherine and Henry's infertility was not considered a big social problem until the King's first son died unexpectedly. This led to Catherine being under the light of guilt, and rumors began to diffuse around her sterility. She started to feel the psychological pressure of not being able to give a heir to the throne and spontaneously, but in tears, offered the King to send her to a convent and replace her. The King reassured her that there would be no divorce and that Lord would provide her with children. Catherine initiated a series of complex treatments for “her” infertility suggested by doctors, diviners, and magicians; she drank pregnant animals’ urine or a mixture of unicorn horn and ivory dissolved in water; she ate powdered sexual organs of cats and other animals; and she refused to ride mules because of the general belief that sterility could be transmitted by infertile animals. She was the culprit, even though her husband Henry had a penile malformation characterized by severe curvature and hypospadias. Henry's responsibilities were not even considered when his mistress Diana (already a mother of two children), failed to give Henry a child as well. Henry's infertility was only addressed in 1543 by two renowned doctors, Nicolas Venette and Jean Fernel, who judged that Henry's malformation was sufficient to cause infertility. In particular, Fernel, who was considered a “master of medicine in the school of medicine of the 16^th century”, prescribed using different coital positions to improve sperm deposition to compensate for Henry's penile curvature and hypospadias. Catherine and Henry finally achieved their first child, Francis, in January 1543, followed by numerous offspring: Catherine finally gave birth to two twins in 1556, at the age of 37 years. The risk of conviction that weighed on Catherine due to the couple's infertility was averted by an accurate medical consultation, which highlighted her husband's andrological problems. Furthermore, the cure for this infertility changed the course of history, providing heirs to the French throne. ¹⁷ , ¹⁸

Since the reactions ranged from the extremely religious view of infertility as a curse from God or the work of the devil to the rational medical conception of it as a kind of disease to be cured, it is very hard to understand the general attitudes of ordinary people toward infertility. ¹⁹

The examples that can be reconstructed in the archives, referring to upper‐class families, confirm that the interpretation of infertility as a disease was widespread and many couples referred to the doctor to receive the adequate treatment. ¹⁹ However, it is possible that the lower strata of the population had a different conception and resorted to the work of midwives and charlatans. ²⁰ While it was believed that witches could be the cause of infertility or, on the contrary, favor a pregnancy, miracle records kept by saints’ shrines include instances where the saints were said to cure infertility and other reproductive problems such as repeated miscarriages. Popular medicine knew numerous remedies considered useful for treating infertility as well. ²¹ , ²² Great belief in faith healing and supernatural power was widespread in the following centuries, so midwives used to use herbs, relics, charms, and incantations. ²¹

1.4. Modern period

With the development of anatomy and the use of the microscope, the Dutch merchant and naturalist Anton van Leeuwenhoek discovered and studied the spermatozoon. ²³ In 1786, Lazzaro Spallanzani demonstrated that spermatozoa were essential to fertilization and proved them to have a nucleus and cytoplasm. Some years later, in 1827, Albert von Kölliker proved the true origin of spermatozoa, originating in the testicular cells and fertilizing the ovum, which then underwent segmentation. ²⁴

In fact, in the early modern period, women were not automatically blamed for the couple's lack of children. This belief spread because women, often absent in historical sources, were at the center of medical discussions about infertility. Men were not contemplated in this discussion due to the patriarchal, misogynistic, and gendered assumptions of the early modern society. However, men knew they could have this problem, so much so that they consumed large doses of drugs to combat infertility.

Such awareness is clearly stated by the mid‐17^th century surgeon John Tanner in his “The Hidden Treasures of the Art of Physick” (1659): “Before you try these uncertain conclusions upon the Woman, examine the man, and see if the fault be not in him. It is known thus, if the man be unable to raise his yard, if he want Sperm, if he hath a swelling in his Stones, or if he have the Running of the Reins, he is not fit for Venus School. If the man be of an effeminate Spirit, if he hath no Beard, if he be long casting forth his Seed, and taketh little delight in the act, and the Woman in the act feeleth his Seed cold, be sure the man is unfruitfull. ²⁵ ”

There are numerous studies between 1700 and 1800 that deal with the possibility that the lack of children depends on the man's semen: the cause could be found in organic problems, anatomical dysfunctions, or psychological disorders. ²⁶

1.5. Infertility in the Christian world

Western civilization has defined itself as Christian for a long time. It is therefore appropriate to question the role and responsibility that Christianity has had in the presented situation of gender disparity. Christianity had its cultural and ideal matrix in the biblical experience and in the history that the Old Testament tells: that of the people of Israel, who lived their events in the eastern Mediterranean area, from whom Jesus Christ and the first members of the community who believed in him came. In most of its texts, the Old Testament reflects the patriarchal and chauvinist mentality typical of Eastern society at the time; only sporadically can there be identified female figures who embody a model of ideal values to follow. ²⁷ Actually, women had a secondary place in society, and from a legal point of view, they were considered more as an object than as a people. ²⁷ In addition to this, the typical structure of Israeli families was polygamous, thus worsening the condition of women. The coexistence of multiple female figures caused many complications, for example, a sterile woman was considered to be inferior, and, therefore, jealousy toward fertile women inevitably developed. Moreover, the husband's inevitable preferences could be the cause of great rivalry between wives. ²⁷

In the Old Testament, three childless women are described whose infertility was relieved by God's intervention so that they could give birth to important patriarchal leaders. ²⁸

Sarah, Abraham's wife, bore their son, Isaac, at the age of 90, and only a few emotional reactions are recorded in the Bible: “And the Lord said to Abraham, why did Sarah laugh and say shall I indeed bear a child now that I am old”; “[…] then Sarah dealt harshly with her [Hagai, Abraham's other wife and the mother of Ishmael] and she ran away from her.” (Genesis, 18:13). ²⁸ Even less is known about the infertility of the mother of Samson, who is cited only as “the wife of Manoah”: “And the angel of the Lord appeared to the woman and said to her ‘although you are barren, having no children you shall conceive and bear a son’.” (Judges, 13:1). ²⁸ Conversely, the third woman, Hannah, mother of the prophet Samuel, is described in detail, highlighting her feelings and reactions to her infertility condition, so that she even presents with a typical picture of depression: “[…] her rival [Penninah, the other wife of Elkanah] used to provoke her severely, to irritate her because the Lord had closed her womb. Therefore Hannah wept and would not eat. Her husband said to her ‘Hannah why do you weep? Why do you not eat? Why is your heart so sad?’ […] She was deeply distressed and prayed to the Lord and wept bitterly.” (Samuel, 1:6‐10). ²⁸

Although Hannah's inner reality is described extensively, her dishonorable infertility can be healed only by divine intervention; all she can do is only pray and wait for God's grace, as well as Samson's and Isaac's mothers, in a condition of absolute passivity and submission, without the possibility of a male being responsible for infertility is taken into account.

1.6. Infertility in the Islamic world

After having addressed the topic of infertility in the Bible and Christianity, it is essential to have an overview of the role of women and couple infertility in the Islamic religion, one of the major faiths in the world. Motherhood in Islam holds the most elevated status among all other relationships; “Paradise lies at the feet of mothers” as said by Prophet Muhammad. Although parenthood and family are highly regarded in Islamic society, the Qur'an, the main sacred text for Muslims, firmly claims that not every couple will conceive and that not all conception will come to births: “To Allah belongs the dominion of the heavens and the earth. He creates as He wills: He bestows female offspring upon whom He wills, and bestows male offspring upon whom He wills. Or He bestows both males and females and He renders barren whom He wills. Verily, He is the All‐Knower and is able to do all things.” (The Counsel: Verses 49−50). ²⁹ Therefore, infertility, as well as abortion, are viewed as a result of God's will, which can concern both men and women. Interestingly, Aisha, the last and youngest of Muhammad's wives, never conceived a child. In one of the famous hadith (“anecdotes”) regarding the Prophet, he is reported to say: “O Servants of Allah, seek medical treatments for your ailments, for there is no disease for which Allah has not created its cure except one, that is senility” thus referring to his age as the responsible factor for couple infertility (it is believed that Aisha was 9−10 years old and Muhammad was 50 at the time of their first sexual intercourse). ²⁹

Although these appear to be the premises for an equal attribution of responsibility between genders for infertility in couples, it is reasonable to consider the general context in which they are evaluated.

In the Qu'ran, numerous passages refer to the condition of women; since they are subject to interpretation (‘ijtihad’), according to some opinions they foresee a clear supremacy of men over women, whereas according to others, they are aimed at a progressive improvement of the condition of women compared to pre‐Islamic Arab society. ³⁰ However, in the Qu'ran a woman's testimony is said to be worth half that of a man, and as long as a woman remains in the family, she is subject to the authority of her father; later on, when she marries, she passes under the authority of her husband. ²⁹ A recently published literature review about Muslim women's experiences with infertility describes some form of humiliation or abuse perpetrated by their husbands or their families among the majority of participants. ³¹ , ³² Additionally, Islamic women experiencing infertility also reveal situations, in which they feel socially isolated, dispossessed, and excluded, pointing out the social stigma of the infertility they live with. ³³ , ³⁴

1.7. Contemporary age and Italian context

The physiology of reproduction has attracted many scholars over the last centuries, providing important contributions and developing novel techniques of therapeutic insemination. However, in the contemporary age, the beliefs survive that infertility is not life‐threatening nor leads to major bodily dysfunction, conditioning the investment in research, ³⁵ and perpetuating, above all in certain circles, the belief that the responsibility of a childless couple always rests with women, who experience greater psychological stress. ³⁶ , ³⁷

In this scenario, the authors of this review are keen to present some fundamental innovations made in the Italian reality, whom they are close to, that may contribute to a future solution to the so‐far depicted gender gap. In Italy, the National Permanent Conference of the President of the School of Medicine and Surgery has developed a core curriculum for medical education, trying to balance the importance of male and female factors in determining reproductive health and diseases. This would lead to a progressive improvement in the way the future healthcare providers will manage couple infertility. Nevertheless, the biggest challenge remains to be faced: to destroy the millennial belief that infertility—at first instance—is a female‐driven problem.

Noteworthy, in the Tuscany region, a territorial andrological service has been established to implement the process of care for infertile couples and increase access for young males and male partners of infertile couples to a specialistic evaluation of their reproductive status. Moreover, the “Center for the Prevention, Diagnosis and Treatment of Infertility” of Careggi Hospital in Florence was also created, which established an innovative health model where gynecologists and andrologists simultaneously evaluate, in an integrated way, both partners, to better manage their reproductive pathway. According to an innovative couple infertility management model, at the first visit, a simultaneous andrological evaluation for the male partner and a gynecological evaluation for the female partner are provided. All male partners undergo a structured interview, a general and andrological visit and complete some validated questionnaires in order to investigate psychological, sexual, and lifestyle aspects. Then, a sperm analysis, transrectal prostate, and testicular ultrasound evaluation, hormonal and metabolic blood tests as well as sperm/urine cultures if needed, are requested. At the end of the multidisciplinary couple visit, the two specialists decide together the most appropriate diagnostic–therapeutic workflow to obtain pregnancy.

2. CONCLUSION

This short review reconstructs a complex network of cultural narratives, medical epistemologies, and gender‐normative references to highlight some moments in the history of the concept of infertility, starting from the responsibility attributed exclusively to women, whose central role in some ancient societies was determined by their ability to procreate, up to the medicalization of infertility, which contributed to sharing with men this participation in the impossibility of having children (summarized in Table 1). In this journey, we highlight junctions and metaphors linked to particular historical moments as well as to cultural and religious constructs. Language also contributes to defining this path through the passage from “sterility” to “(in)fertility”, through the rhetorical implications that reflect the cultural and social attitude. ³⁸

TABLE 1.

Summary of the main approaches to male infertility according to different historical periods and relative sources.

Historical period	Main approach to male infertility	Main sources
Classical antiquity	Attributed to something outside of human control that depends merely on the constitution of the body or on lifestyle factors that could lead to the loss of reproductive ability in men, generally untreatable. Incompatibility of the couple also possible.	Hippocratic writers and Aristotle.
Roman world	Fertility considered as a central point in the life of the couple; couple's infertility responsibility often attributed to women.	Roman historians and orators.
Middle Ages	Ranging from an extremely religious view of infertility as a curse from God or the work of the devil to the rational medical conception of it as a kind of disease to be cured.	Archives.
Modern period	Men usually not contemplated in the medical discussion about infertility due to the patriarchal, misogynistic, and gendered assumptions of early modern society, despite spermatozoa discovery and male consumption of drugs against infertility.	Scientific works and reports of the time.

AUTHOR CONTRIBUTIONS

Conceptualization: Linda Vignozzi and Donatella Lippi. Data collection: Linda Vignozzi, Sarah Cipriani, and Donatella Lippi. Formal analysis: Linda Vignozzi and Donatella Lippi. Drafting the article: Linda Vignozzi, Sarah Cipriani, and Donatella Lippi. Critical revision and supervision: Linda Vignozzi, Sarah Cipriani and Donatella Lippi.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Vignozzi L, Cipriani S, Lippi D. Why couple infertility is historically a female‐driven problem? Andrology. 2025;13:675–680. 10.1111/andr.13716

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this review as no datasets were generated or analyzed during this study.